Appendix A: Training Program for Study Group (Motor Relearning Program) Exercises

Task-specific training were performed for study group (MRP) based on the motor relearning program for 8 weeks (3
sessions per week; 1 hr. per session; 24 sessions). Each MRP rehabilitation session includes the following exercises:

(1) Bed Mobility and Sitting Up Over the Side of The Bed

Supine Trunk Rotation

REPS: 10 | SETS: 3 | HOLD: 5-10 sec.

Starting position:
The patient should lie on their back in a supine position, with their knees flexed at a 90-degrees and the feet flat on the bed.
Exercise:
The patient should slowly rotate their knees and hips to one side while keeping the upper body flat on the bed. They should aim to
rotate as far as they comfortably can without causing any pain or discomfort, until they feel a stretch in the trunk. Hold this position
for 5-10 seconds. Then, slowly rotate the knees
and hips back to the starting position. Repeat
the same movement on the other side, keeping
the upper body still while rotating the lower
body. This completes one repetition. The patient
should perform a total of 3 sets of 10 repetitions,
with a short rest period between sets.
The patient should start with a small range of
motion and gradually increase the rotation as
they become more comfortable with the
exercise. They should keep the neck and
shoulders relaxed throughout the exercise and
avoid tensing up or straining the neck.

Bridging Exercise
REPS: 10 | SETS: 3 | HOLD: 2-3 sec.

Starting position:
The patient should lie on their back in a supine position, with their hips flexed at 45-degrees, knees flexed at a 90-degrees, and the
feet flat on the bed. They should place their arms at the sides with palms facing down and keep their feet hip-width apart, ensuring
they are aligned with the knees and hips.
Exercise:
The patient should begin by contracting their core muscles to stabilize the spine and slowly raise their hips/pelvis from the bed until
their hips are extended (0-degrees or slightly less) and the pelvis is level. This motion is called a concentric contraction. During the
elevation, they should make sure the lumbar spine is in a neutral position, and the pelvis does not rotate. They should hold this
position for 2-3 seconds and focus on squeezing their glutes to maintain the elevated position. Then, they should slowly lower the
hips/pelvis back down to the bed in a controlled manner. This motion is called an eccentric contraction. They should make sure not
to let the pelvis rotate during the lowering motion.
The patient should perform a total of 3
sets of 10 repetitions, with a short rest
period between sets. They should
keep the neck and shoulders relaxed
throughout the exercise and avoid
tensing up or straining the neck.
Single-Leg Bridge Exercise (Bridging Exercise Progression)
REPS: 10 | SETS: 3 | HOLD: 2-3 sec.

Starting position:
The patient should lie on their back in a supine position, with their arms at your sides and palms facing down. Keep the leg on the
affected side pressed on the bed, with a 45 degrees hip joint flexion and a 90 degrees knee flexion. The leg on the unaffected side
should be fully extended and comfortably laid down.
Exercise:
The patient should begin by contracting their core muscles to stabilize the spine and slowly raise their affected side hips/pelvis from
the bed until their hips are extended (0-degrees or slightly less) and the pelvis is level. During the elevation, they should make sure
the lumbar spine is in a neutral position, and the pelvis does not rotate. They should hold this position for 2-3 seconds and focus on
squeezing their glutes to maintain the elevated position. Then, they should slowly lower the hips/pelvis back down to the bed in a
controlled manner. After completing the exercise on the affected side, they should alternate legs and repeat the same exercise on the
unaffected side.

The patient should perform a total of 3 sets

of 10 repetitions for each leg or side, with
a short rest period between sets. They
should keep the neck and shoulders
relaxed throughout the exercise and avoid
tensing up or straining the neck.

Sitting Up Over the Side of Bed

REPS: 5 both sides | SETS: 1

Starting position:
The patient should lie on their back in a supine position, with their arms at their sides.

Exercise:
The patient should turn onto the affected side by first rotating and flexing the neck to the side, followed by flexion of the hip and knee,
flexion of the shoulder, and protraction of the shoulder girdle, and then rotation within the trunk to face the edge of the bed. From this
position, the patient should prepare to sit up by first laterally flexing the neck, then laterally flexing the trunk (abducting the lower arm
across), and then lifting and lowering the legs over the side of the bed. Next, the patient should sit up over the side of the bed, keeping
the affected arm close to the body and using the intact arm to push themselves up. They should try to keep their head and trunk
aligned as they sit up.
Return to the lying position by lowering the legs
back onto the bed and then lying back down on
their side. Repeat this exercise for 5 repetitions
on the affected side, and then repeat the entire
sequence on the unaffected side for another 5
repetitions.
While performing the exercise, it is important to
avoid rotating the neck and flexing it forward
instead of laterally. It's also important to avoid
pulling with the unaffected hand or hooking the
affected leg with the unaffected leg in order to
get the legs over the side of the bed. The
therapist can assist with the movement as
needed to ensure proper form and safety, but
they should also encourage the patient to
progress without assistance as they become
more comfortable and stable with the exercise.
 (2) Balanced Sitting

Seated Lateral Trunk Flexion

REPS: 10 | SETS: 3 | HOLD: 2-3 sec.

Starting position:
The patient should sit at the edge of the bed with their feet flat on the ground, positioned hip-width apart and their knees bent at a 90-
degrees. The patient should maintain a straight back and relaxed shoulders.
Exercise:
The patient should slowly shift their weight to the right side and place their right elbow on the bed, keeping the forearm perpendicular
to the body. The left arm should be relaxed and resting on the left thigh. Hold this position for 2-3 seconds, then tighten the core
muscles and slowly push back up to the center. Repeat the same movement on the left side.
The patient should alternate between the left
and right sides, performing a total of 3 sets of
10 repetitions on each side, with a short rest
period between sets.
The patient should control the movement
with their core muscles, particularly the
obliques, rather than using momentum or
gravity to move up and down. Avoid arching
the lower back or rounding the shoulders.

Sitting Trunk Rotation

REPS: 10 | SETS: 3 | HOLD: 5-10 sec.

Starting position:
The patient should sit at the edge of the bed with their feet flat on the ground, positioned hip-width apart and their knees bent at a 90-
degrees. They should place their hands on the thighs or on the side of the bed for support.
Exercise:
The patient should slowly twist their torso to the left, using their
hands to gradually deepen the stretch and attempting to look
behind at the therapist, without over-rotating or twisting the neck
too much. They should keep their hips facing forward and avoid
overstretching. Hold the stretch for 5-10 seconds, then return to
the center. Repeat the stretch on the other side by twisting the
torso to the right.
The patient should alternate between the left and right sides,
performing a total of 3 sets of 10 repetitions on each side, with
a short rest period between sets.
Sitting Multidirectional Reaching
REPS: 5 | SETS: 1

Starting position:
The patient should sit upright on a chair or bench with their feet flat on the ground. The therapist should place a small object, such as
a small weight, at different heights and positions in front of the patient.
Exercise:
The patient should slowly reach forward with one arm to pick up the object. The therapist should assist by guiding the affected upper
limb to reach out and pick up the object from the designated location. Then, return the object to its location and repeat the exercise,
but this time reach out with the other arm to pick up the object. Repeat the exercise again, but this time reach out to the side to pick
up the object from a different location. Finally, repeat the exercise one more time, this time reaching down to pick up the object from
the ground.
The patient should alternate between these three reaching directions, performing one set of 5 repetitions in each direction with each
arm. As the patient progresses, the therapist should reduce their assistance until the patient is performing the exercise without any
assistance.

(3) Standing Up and Sitting Down

Standing Up and Sitting Down

REPS: 10 | SETS: 3

Starting position:
The patient should sit upright near the front of a sturdy chair with a flat seat and a backrest, with their feet positioned s lightly behind
the knees and shoulder-width apart.
Exercise:
The patient should clasp their hands together or interlock their fingers in front of the chest. The patient should maintain equal weight
on both legs and slowly lean forward, shifting their weight forward, and push up through their feet until they are fully extended and
the back is straight. They should keep their hands
clasped together in front of the chest throughout the
movement. Then, the patient should slowly lower
themselves back down onto the chair by bending the
knees and hips. They should keep their back straight
and their hands clasped in front of the chest.
The patient should repeat the standing up and sitting
down movement for 3 sets of 10 repetitions, resting
for 30-60 seconds between each set.
 (4) Balanced Standing

Standing Multidirectional Reaching

REPS: 5 | SETS: 1

Starting position:
The patient should stand in front of the therapist with their feet
shoulder-width apart and their arms at the sides. The therapist
should hold a small object at different heights and positions in front
of the patient.
Exercise:
The patient should slowly reach forward with one arm to pick up
the object from the therapist's hand while maintaining balance and
stability. Then, they should return to the starting position and
repeat the exercise by reaching out to the side to pick up the
object from the therapist's hand. They should repeat the exercise
again by reaching backward to pick up the object from the
therapist's hand. Finally, they should repeat the exercise by
reaching downward to pick up an object from the floor. When
reaching downward, they should make sure to bend their knees
and keep their back straight to avoid straining the lower back.
The patient should alternate between these four reaching
directions, performing one set of 5 repetitions in each direction
with each arm.

To progress, narrow the patient's base of support, which means

bringing their feet closer together to make it more challenging to
maintain balance. The patient should start the exercise
progression by standing with their feet hip-width apart instead of
shoulder-width apart. Then, continue to narrow the base of support
by bringing their feet even closer together until they are together,
which will further challenge their balance and stability.
Standing Heel and Toe Raises
REPS: 10 | SETS: 3 | HOLD: 2-3 sec.

Starting position:
The patient should stand upright with both feet flat on the ground, about hip-width apart, and hold onto a sturdy countertop or the
back of a sturdy chair for balance and stability.
Exercise:
The patient should slowly raise their heels off the ground (rise up onto their toes) as high as they are comfortable while keeping the
upper body and knees straight. Hold for 2-3 seconds, and then slowly return to the starting position. Next, they should slowly raise
their toes as high as they are comfortable while
maintaining good posture, taking their weight on
their heels. Hold for 2-3 seconds, and then return
to the starting position.
The patient should perform a total of 3 sets of 10
repetitions for each movement, with a short rest
period between sets.

The patient should begin by using both hands to

maintain balance, then progress to just using one
hand, and finally no hands. Additionally, as the
patient progresses, they should move back and
forth a bit faster and hold for a few seconds in the
toe and heel positions.

Single Leg Standing

REPS: 5 | SETS: 3 | HOLD: 10 sec.

Starting position:
The patient should stand upright nearby a sturdy countertop or the back of a sturdy chair and hold it with one hand to help with balance
and stability, with both feet flat on the ground, about shoulder-width apart.
Exercise:
The patient should slowly lift one leg off the ground until
they are balanced on the other leg. They should
maintain balance standing on one leg for a count of 10
seconds, and then slowly lower the leg back down to the
starting position. The patient should repeat the same
exercise with the other leg. The patient should alternate
between the left and right legs, performing a total of 3
sets of 5 repetitions on each leg, with a short rest period
between sets.

The patient should start by holding onto a support with

one hand for balance, and then progress to performing
the exercise without any support. Additionally, as the
patient progresses, they can try doing the exercise with
their eyes closed for an extra challenge.
Standing Knee Extension with Heel Strike
REPS: 10 | SETS: 3 | HOLD: 2-3 sec.

Starting position:
The patient should stand upright nearby a sturdy countertop or the back of a sturdy chair and hold it with one hand to help with balance
and stability, with both feet flat on the ground, about shoulder-width apart.
Exercise:
The patient should start by shifting their weight onto one
leg and slightly lifting the other leg off the ground. Next,
they should slowly extend the lifted leg forward while
keeping the knee straight and simultaneously strike the
ground with the heel. They should hold this position for 2-
3 seconds, and then slowly lower the leg back down to the
starting position. The patient should repeat the same
exercise with the other leg. The patient should alternate
between the left and right legs, performing a total of 3 sets
of 5 repetitions on each leg, with a short rest period
between sets.
The patient should start by holding onto a support with one
hand for balance, and then progress to performing the
exercise without any support.

(5) Practice of Walking

Practice of Walking Components

REPS: 3 | 1 REP = 10 meters

Starting position:
In a safe, flat, and level surface room free from obstacles, the patient should wear appropriate footwear. The therapist should be close
to the patient to guide them through the movement by providing physical assistance, verbal and visual cues to ensure proper form
and technique to maintain a proper gait pattern, and to avoid compensating with other body parts during the exercise.
Exercise:
Practice of walking components: Break down the walking cycle into its two main phases: stance and swing.
Step 1: Stance phase practice
The stance phase is the part of the walking cycle when the foot is in contact with the ground. To practice this phase, the patient should
start by standing with feet hip-width apart, with weight evenly distributed between both feet. Then, the patient should practice shifting
their weight from one foot to the other, paying attention to their balance and weight distribution. The exercise should be repeated with
both legs.
Step 2: Swing phase practice
The swing phase is the part of the walking cycle when
the foot is off the ground and swinging forward. To
practice this phase, the patient should start by
standing with feet hip-width apart, with weight evenly
distributed between both feet. Then, the patient
should practice lifting one foot off the ground and
swinging it forward and backward in a smooth,
controlled motion, as if taking a step. Encourage the
patient to maintain good posture and use their hip
muscles to control the movement and maintain
balance throughout the exercise. The exercise should
be repeated with both legs, gradually increasing the
range of motion and speed of the swing until they can
take full steps forward and backward.
Step 3: Practice of walking itself
Once the patient has demonstrated good control and coordination of the stance and swing
phases, as well as an integrated walking pattern, begin practicing walking itself. The patient
should start with short distances, slow speeds, and assisted walking, where the therapist provides
support and guidance as needed. Gradually increase both walking distances and speeds, as well
as decrease the amount of assistance as the patient's ability improves. Encourage the patient to
focus on their foot placement, weight distribution, posture, and balance as they walk.

Backwards Walking
REPS: 3 | 1 REP = 10 meters

Starting position:
In a safe, flat, and level surface room free from obstacles, the patient should stand upright with their feet shoulder-width apart and
their arms at their sides. The therapist should stand behind the patient for safety and to guide them through the movement by providing
physical assistance, as well as verbal and visual cues to ensure proper technique to maintain a proper gait pattern.

Exercise:
The patient should slowly start walking backwards, taking small and controlled steps. Keep the head and neck in a neutral position
and avoid looking over the shoulder or down at the feet, as
this can disrupt the balance. Instead, use the sense of
balance and body awareness to maintain stability. Try to
maintain a slow and steady pace while walking backwards.
If the patient feels unsteady or unsure, they can start by
holding onto something close by, like a wall or countertop.
This can help them maintain balance and build confidence
as they get used to the exercise. Walk backwards for a
distance of 10 meters. Once the patient reaches the end of
the 10-meter distance, they should stop and turn around
slowly, taking a moment to reorient themselves before
starting the exercise again.

Repeat the exercise for a total of 3 repetitions, with a short

rest period in between each repetition. As the patient
becomes more confident and stable, they can try doing the
exercise without holding onto anything for support.
Sideways Walking
REPS: 3 | 1 REP = 10 steps both sides

Starting position:
In a safe, flat, and level surface room free from obstacles, the
patient should stand upright with their feet shoulder-width apart
and their arms at their sides. The therapist should stand in front of
the patient for safety, providing physical assistance, verbal and
visual cues, and ensuring proper technique. The therapist should
also ensure that the patient avoids compensating with other body
parts during the exercise.
Exercise:
The patient should step sideways in a slow and controlled manner,
starting by moving one foot to the side, followed by the other foot.
It's important to avoid dropping the hips as the patient steps. After
taking 10 steps in one direction, the patient should change
directions and repeat the same steps in the other direction. The
exercise should be performed for 3 repetitions of 10 steps each
direction, with a short rest period in between each repetition.
The goal of the exercise is to increase glute activation and dynamic
balance and stability with lateral weight shifting. As the patient
becomes more confident and stable, the therapist can gradually
step away and provide only supervision.

Braiding Walking
REPS: 3 | 1 REP = 10 steps both sides

Starting position:
In a safe, flat, and level surface room free from obstacles, the patient should stand upright with their arms at their sides. The therapist
should stand behind and to the side of the patient for safety, providing physical assistance, verbal and visual cues, and ensuring
proper technique. The therapist should also ensure that the patient avoids compensating with other body parts during the exercise.
Exercise:
The patient should begin the exercise by taking a side step
to the left, shifting their weight onto the left leg. Next, cross
the right leg up and across in front of the left leg, as if braiding
the legs. Again, shift their weight onto the right leg, making
sure to maintain a stable center of gravity. Take another side
step to the left, shifting their weight back onto the left leg.
Cross the left leg backward and behind the right leg, again
as if braiding the legs. Then, shift their weight back onto the
right leg, maintaining a stable center of gravity. After taking
10 steps in one direction, the patient should change
directions and repeat the same steps in the other direction.
The exercise should be performed for 3 repetitions of 10
steps each direction, with a short rest period in between
each repetition.
Make sure to maintain a slow and controlled pace throughout the
exercise, focusing on maintaining balance and stability. As the
patient becomes more confident and stable, the therapist can
gradually step away and provide only supervision. Additionally, the
therapist should ensure that the patient avoids compensating with
other body parts during the exercise.

Heel-to-Toe Walking (Tandem Walking)

REPS: 3 | 1 REP = 10 meters

Starting position:
In a safe, flat, and level surface room free from obstacles, the patient should stand upright with their feet together and arms at their
sides. The therapist should stand close to the patient for safety, providing physical assistance, verbal and visual cues, and ensuring
proper technique.
Exercise:
The patient should lift one foot and place it directly in
front of the other foot so that the heel touches the toe
of the other foot. Then, take a step forward, placing
the other foot in front of the one they just moved.
Continue to walk heel-to-toe for a distance of 10
meters while keeping their eyes fixed on a spot in front
of them to help with balance. Once the patient reaches
the end of the 10-meter distance, they should stop and
turn around slowly, taking a moment to reorient
themselves before starting the exercise again. Repeat
the exercise for a total of 3 repetitions, with a short
rest period in between each repetition.
As the patient becomes more confident and stable,
they should try not to rely on arm support to maintain
their balance, and the therapist can gradually step
away and provide only supervision.

Walking with Head Turns and Tilts

REPS: 3 | 1 REP = 10 meters

Starting position:
In a safe, flat, and level surface room free from obstacles, the patient should stand upright with their shoulder-width apart and arms
at their sides. The therapist should stand close to the patient for safety, providing physical assistance, verbal and visual cues, and
ensuring proper technique.
Exercise:
The patient should start walking slowly, taking small and controlled
steps while turning their head to the right and left, then tilting their
head up and down. They should make sure to maintain their balance
and focus on their breathing. If the patient feels dizzy, they should
stop and take a deep inhale and exhale. Walk for a distance of 10
meters. Once the patient reaches the end of the 10-meter distance,
they should stop and turn around slowly, taking a moment to reorient
themselves before starting the exercise again. Repeat the exercise
for a total of 3 repetitions, with a short rest period in between each
repetition. As the patient becomes more confident and stable, the
therapist can gradually step away and provide only supervision.